New Hire Employment Application

GALERON CONSULTING AGENCY
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New Hire Employment Application
1. Employer Information

Employer: GALERON CONSULTING AGENCY

Address: 501 Cambria Ave., Suite 108

City/State/ZIP: Bensalem Township, Pennsylvania, 19020

Telephone: 1-800-507-2157

It is the policy of GALERON CONSULTING AGENCY to provide equal employment opportunities to all applicants and employees without regard to any legally protected status such as race, color, religion, gender, national origin, age, disability, or veteran status.

2. Applicant Information
Applicant Full Name*

First NameLast Name
Home Address*
County*
City/State/ZIP*
Number of years at this address*
Email Address *
Mobile Phone*
Day Phone *
Evening Phone
3. Emergency Contact

Who should be contacted if you are involved in an emergency?
Contact Name*
Relationship to you*
Address
City/State/ZIP
Daytime Phone*
Evening Phone
JOB TITLE: DIRECT SERVICE PROFESSIONAL
4. JOB POSITION APPLYING FOR:*
5. Salary Desired: $*
Per/hr*
6. Who referred you to our company*
Do you have any friends or relatives who work at GALERON CONSULTING AGENCY. If yes please list here
7. Have you applied to our company previously?*

YesNo
If yes when
8. Are you at least 18 years old?*

YesNo
9 How will you get to work*
10. Are you willing to work any shift, including nights and weekends?*

YesNo
If no please state any limitations
HOURS & DAYS AVAILABLE FOR WORK
Full Time
Part-time
On-Call
Split Shift
Indicate Days and List Hours Available for Work:
Sunday
From
To
Monday
From
To
Tuesday
From
From
To
Wednesday
From
To
Thursday
From
To
Friday
PRINT FULL NAME*
-
From
To
Saturday
From
To
What is the minimum number of hours you will work in one day*
What is the maximum number of hours you will work in one day*
TYPE OF POSITION(S) PREFERRED
TYPE OF POSITION(S) PREFERRED*

CNA (Certified Nursing Assistant)HHA (Home Health Aide)PCA (Personal Care Assistant)Live-In CaregiverHome Maker / Chore WorkerCompanion CaregiverRespite Care WorkerEmployment Support SpecialistJob CoachJob Developer / Job FinderCareer Assessment FacilitatorSkills Development SpecialistCommunity Participation Support (CPS) StaffDirect Support Professional (DSP)In-Home and Community Support WorkerTransportation Provider / DriverSupports BrokerTransitional Work SpecialistHomemaker / Chore AideBehavioral Support Aide (if applicable)Administrative Support (Office/Remote)Scheduler / Care CoordinatorField SupervisorOther (Please Specify)
Other
Live-in care usually requires that you be in a client's home continuously for 3-4 days at a time every week. Indicate which shifts you will accept:
Weekdays (Monday a.m. to Friday a.mWeekends: (Friday a.m. to Monday a.m)
11. If applicable, are you available to work overtime?

YesNo
12 If you are offered employment when would you be available to begin work*
13. If hired, are you able to submit proof that you are legally eligible for employment in the United States?*

YesNo
14. Have you ever been convicted of a felony or misdemeanor?

Yes , I was convicted of on Datein (City), (state) No
THE EXISTENCE OF A CRIMINAL RECORD DOES NOT CONSTITUTE AN AUTOMATIC BAR TO EMPLOYMENT UNLESS RELEVANT TO THE TYPE OF EMPLOYMENT.

15. Applicant's Skills

Please check any current skills that you might have. List any other skills that may be useful for the position you are seeking.
Indicate which of the following you have experience in:*

Observation and ReportingBasic Medical KnowledgeHousekeepingEmergency ResponseGroomingPersonal Care SkillsLaundryNutrional ManagementPersonal HygieneMedication ManagementMeal PreparationCultural CompetencyDressingProblem-Solving and AdaptabilityShoppingCommunication SkillsBowel CareMobility AssistanceTransportationCustomer ServiceBladder CareBathing/ShoweringMedication RemindingFeedingFriendly Reassurance Phone Call or Home VisitAmbulationSocializationToiletingOther
Do you have current First Aid Certification (State Level):
Expiry Date

MonthDayYear
Date
Do you have current CPR?
Expiry Date

MonthDayYear
Date
Have you taken a Food Safety course
Other
Specify
Other
16. Applicant Employment History

List your current or most recent employment first. Please list all jobs (including self-employment and military service) that you have held, beginning with the most recent, and list and explain any gaps in employment. If additional space is needed, continue on the back page of this application.
Employer Name*
Supervisor Name
Address*
CityStateZIP*
Job Duties*
Reason for Leaving*
Dates of Employment MonthYear*

MonthDayYear
Date
Employer Name
Supervisor Name
Address
City/State/ZIP
Job Duties
Reason for Leaving
Dates of Employment Month/Year

MonthDayYear
Date
Employer Name
Supervisor Name
Address
City/State/ZIP
Job Duties
Reason for Leaving
Dates of Employment Month/Year

MonthDayYear
Date
Employer Name
Supervisor Name
Address
CityStateZIP
Job Duties
Reason for Leaving
Dates of Employment Month/Year

MonthDayYear
Date
17. Applicant's Education and Training
College/University Name and Address:
No If yes, degree(s) received:
Did you receive a degree?

YesNo
If yes, degree(s) received:
High School/GED Name and Address*
Did you receive a degree?*

YesNo
Other Training graduate technical vocational
Please indicate any current professional licenses or certifications that you hold
Awards, Honors Special Achievements:
Military Service

YesNo
Branch
Specialized Training
18. References

List any two non-relatives who would be willing to provide a reference for you.
Name*
Address*
City/State/ZIP*
Telephone*
Relationship*
Name*
Address*
City/State/ZIP*
Telephone*
Relationship*
19. Please include any additional information you feel is relevant such as whether you have any contracts with current employers*
Certification
I hereby certify that all the information provided on this job application is truthful and accurate. I understand that any false or misleading information may result in the rejection of my application or, if discovered after employment, immediate termination.

I hereby authorize GALERON CONSULTING AGENCY to contact my former employers and educational organizations for the purpose of verifying my employment history and education.

I also authorize my former employers and educational organizations to disclose and provide GALERON CONSULTING AGENCY with any information pertaining to my previous employment, attendance, grades, and any other relevant information necessary for the purpose of a background check.

Furthermore, I authorize the individuals designated as references on this application to fully and freely communicate information regarding my previous employment and education to GALERON

By signing this application, I acknowledge and agree to these terms and authorize GALERON CONSULTING AGENCY to conduct a background check on me as part of the employment

I HAVE CAREFULLY READ THE ABOVE CERTIFICATION, AND I UNDERSTAND
PRINT NAME*
-
Date*

MonthDayYear
Date
SIGN NAME*

Clear
Date*

MonthDayYear
Date
THIS IS A GALERON CONSULTING AGENCY DOCUMENT.
Should be Empty:

GALERON CONSULTING AGENCY

HOME CARE AGENCY

New Hire Employment Application

HOURS & DAYS AVAILABLE FOR WORK

TYPE OF POSITION(S) PREFERRED

Certification